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CT-guided core needle biopsy for deep facial and skull base lesion

En-Haw Wu, Yao-Liang Chen, Yi-Ming Wu, Shu-Hang Ng Department of Diagnostic Radiology, Chang Gung Memorial Hospital , Linkou, Taoyuan, Taiwan. CT-guided core needle biopsy for deep facial and skull base lesion. Introduction. Dx for deep H&N lesions is crucial but hard.

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CT-guided core needle biopsy for deep facial and skull base lesion

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  1. En-Haw Wu, Yao-Liang Chen, Yi-Ming Wu, Shu-Hang Ng Department of Diagnostic Radiology, Chang Gung Memorial Hospital , Linkou, Taoyuan, Taiwan. CT-guided core needle biopsy for deep facial and skull base lesion

  2. Introduction • Dx for deep H&N lesions is crucial but hard. • Inaccessible clinically. • Posing surgical risk. • Alternative approach • Image-guided fine needle aspiration (FNA) / core needle biopsy (CNB)

  3. US-guided needle approach • US-guided CNB • Real-time; no radiation. • Reliable in Dx of H&N lesions Radiology 2002;224:75–81; Head Neck 2007;29:1033–40 • Limited acoustic window in deep H&N due to intervening osseous and vital structure. Radiographics 2007;27:371–90.

  4. CT-guided FNA • Reported diagnostic yield 90.3% and accuracy 88.4% in 216 cases. Sherman et al. , AJNR Am J Neuroradiol 25:1603–1607 • Result depends on cytology expertise, may be biased by specimen quality. Howlett et al., J Laryngol Otol 2007;121:571–9

  5. CT-guided CNB • W/ automated cutting needle • Offering histopathological / immunochemical study. • Challenging in deep H&N due to intervening neurovascular structure. • Reported accuracy as 86.7% in 18 biopsies. Conner et al, Clin Radiol 2008; 63(9): 986-94.

  6. Material and methods • Patients • From 2004 to 2010, • 31 patients / 31 biopsies of deep head and neck lesion. • Mean age ± SD (years)= 52.16 ±11.38. • Gender (F/M) = 5/26 • H&N cancer pts= 24 • Lesions • Clinically inaccessible • Deep supra-hyoid head and neck

  7. Biopsy Technique • CT images reviewed for best needle approach • Neurovascular structure. • IV contrast enhancement. • Local anesthesia, 1 % Lidocaine. • Positioning of patient's head • Tilting away from the lesion site.

  8. Biopsy Technique • Co-axial needle set – CardinalHealth / Temno® Biopsy Systems. • 17/19G introducer system + 18/20G semi-automatic tru-cut biopsy needle

  9. Needle approach Connor et al, Clin Radiol 2008; 63(9): 986-94. Gupta et al, Radiographics 2007; 27(2): 371-90. • Subzygomatic (sigmoid notch) • Paramaxillary (retromaxillary) Tu, A.S., et al., AJNR Am J Neuroradiol 1998; 19(4): 728-31. • Retromandibular (transparotid)

  10. Diagnosis • Diagnoses standard • histopathology Dx from surgical excision. • treatment response. • clinical follow-up. • Diagnostic yield = adequate / all specimen. • Diagnostic accuracy = needle dx / final dx.

  11. Case presentation

  12. 59 y/o male, hx of oral cancer, with right masticator space tumor. • 17 / 18 G needle, paramaxillary approach, three needle passes. • Yield: recurrent SCC. • Tx: RT.

  13. 37 y/o male with right parapharyngeal lesion. • 19 / 20 G, subzygomatic approach, two needle passes. • Yield: fibrosis. • Skull base OP: fibrosis.

  14. Inadequate specimen • 42 y/o male with odynophagia and occasional choking. • Bx: 19/20 G needle, retromandibular approach • Yield: inadequate specimen • Dx: Schwannoma

  15. Sampling error • 76 y/o male with right zygomatic eminence. • Bx: 17/18 G, subzygomatic approach, two passes. • Yield: fibrosis. • OP: meningioma en plaque (diploic meningioma)

  16. Complication • 64 y/o male, with hx of left buccal cancer, s/p OP and RT • BX: 17/18G needle set, subzygomatic approach, two needle passes • Yield: recurrent cancer. • Complication: Local hematoma.

  17. Complication • 40 y/o male, with left deep parotid tumor. • 17/18G needle, retromandibular approach, two needle passes. • Yield: adenoid cystic carcinoma. • Complication: transient facial nerve palsy.

  18. Results

  19. *Rt parapharyngeal schwannoma • †One sampling error • †† Subcutaneous hematoma and transient facial palsy

  20. Discussion * Clin Radiol. 2008 Sep;63(9):986-94.

  21. CT-guided FNA or CNB? • FNA have limited value in treated cancer  prior surgery and irradiation can alter the normal structure. Toh et al, Head Neck. 2007 Apr;29(4):370-7. *AJNR Am J Neuroradiol. 2004 Oct;25(9):1603-7. **Arch Otolaryngol Head Neck Surg. 2000 Mar;126(3):366-70.

  22. Collision lesion • CNB of skull base area in a treated NPC patient • Yielding granulation + recurrent undifferentiated carcinoma. • FNA may not be feasible.

  23. CNB in H&N cancer patients • In subgroup of the 24 H&N cancer patients, • Diagnostic yield = 100 % • Diagnostic accuracy = 100 % • Avoiding unnecessary surgery.

  24. Conclusion • CT-guided CNB • an accurate and safe in deep head and neck areaswith few minor complications (6.5%) • offering tissue diagnosis and avoidance of unnecessary surgery, esp. in H&N cancer.

  25. Thank you www.taiwan.net.tw

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